• Name of IKF/ISCF Promoter:__________________________________________
  • Where is event to be held: ______________________, ____________________
  • What is the DATE of your event: ____/____/____
  • Is the event ___IKF Sanctioned, ___ISCF Sanctioned or ____Both?
  • Are you requesting Venue Liability for your event for $1 Million Coverage at the fee of $450.00?
    • _____ Yes _____No
  • Are you requesting Fighter Medical Insurance from one of the rate packages below?
    • _____ Yes _____No
  • If so, which "PLAN NUMBER" are you requesting: ________

PLAN
NUMBER

Maximum Medical
Benefit

Accidental Death
Benefit

Deductible

Rates

1

$2,500.00

$2,500.00

$2,000.00

$460.00

2

$2,500.00

$2,500.00

$1,500.00

$590.00

3

$2,500.00

$2,500.00

$1,000.00

$700.00

4

$2,500.00

$2,500.00

$500.00

$770.00


5

$5,000.00

$5,000.00

$1,000.00

$840.00

6

$5,000.00

$5,000.00

$500.00

$910.00


7

$10,000.00

$10,000.00

$1,000.00

$1,190.00

8

$10,000.00

$10,000.00

$500.00

$1,400.00


9

$15,000.00

$15,000.00

$1,000.00

$1,490.00

10

$15,000.00

$15,000.00

$500.00

$1,800.00


11

$20,000.00

$20,000.00

$2,000.00

$1,300.00

12

$20,000.00

$20,000.00

$1,500.00

$1,900.00

13

$20,000.00

$20,000.00

$1,000.00

$2,400.00

14

$20,000.00

$20,000.00

$500.00

$2,750.00


15

$50,000.00

$50,000.00

$5,000.00

$920.00

16

$50,000.00

$50,000.00

$2,500.00

$2,900.00

17

$50,000.00

$50,000.00

$1,000.00

$4,000.00

18

$50,000.00

$50,000.00

$500.00

$4,250.00